Sexually Abused Women Skip Pap Smears

Action Points

Sexually-abused girls appear more likely to avoid cervical cancer screening as adults, according to an exploratory study suggesting that the exam brings back the feeling of victimization for some.

Note that almost one in four cited self-worth issues as part of the reason they didn't go for screening as regularly as they should, not just because of embarrassment but also because of scars or other signs of abuse that would be apparent to the screener in some cases.

Sexually-abused girls appear more likely to skip cervical cancer screening as adults, according to an exploratory study suggesting that the exam brings back the feeling of victimization for some.

Only 49% of British women abused as children or young adults had gotten a recommended Pap smear in the prior 5 years as compared with a general population rate of 79% there, Anne Szarewski, MD, of the Queen Mary University of London, and colleagues found.

The surveys completed by women visiting the website of the U.K. National Association for People Abused in Childhood often cited fear, anxiety, and a feeling of powerlessness, the group reported in the October issue of the Journal of Family Planning and Reproductive Health Care.

"One way of coping with the trauma of sexual abuse is to control or avoid the triggers of trauma responses," they wrote. "Intimate gynecological examinations can be particularly stressful for women who have been abused because of the parallels with the abuse situation, for example, perceived loss of control, the power disparity, and the physical sensation of the examination."

However, women who have been sexually abused are at increased risk of cervical lesions, possibly because of early exposure to cancer-related human papillomavirus as well as the risky health behaviors often seen in abused women, such as drug and alcohol abuse.

Many such women are aware of the importance of screening, but "we repeatedly hear that some survivors would rather deal with cervical cancer if it develops than face the experience of regular testing," Sarah Kelly, training and development manager at the abuse survivors' support association, explained in an accompanying editorial.

But the group has also received tips from women on what has helped them have positive experiences with getting a cervical smear test:

Time to talk about the fear and anxiety they are feeling about the test

A friend or supporter present with them during the test

An understanding smear taker

A private and comfortable environment to undress and be tested

A prearranged signal they can use to halt the test at any point

Another point for clinicians to consider is that asking a woman to "try to relax" during the test can trigger anxiety or flashbacks, Kelly noted.

"The word 'relax' is often used by abusers and can be very frightening for survivors; an alternative is to agree a word in advance to use in discussions with the patient," she wrote.

Her organization's website featured a short anonymous survey asking about demographics, cervical screening history, and history of abuse, which 135 sexually-abused women completed.

Of the women eligible for cervical cancer screening, 78% had ever gotten the test done.

Fewer than half had done so within the recommended screening interval, which in England varies from 3 to 5 years depending on a woman's age:

49% at least once in the prior 5 years

42% of women ages 25 to 49 within 3 years

The survey also asked women to explain the main reasons for not ever having had a Pap smear, or sometimes putting it off when invited to do so, as well as for their suggestions to make abused women more likely to get screened.

Nearly all of the women (124 of 135) provided open-ended responses.

Almost one in four cited self-worth issues as part of the reason they didn't go for screening as regularly as they should, not just because of embarrassment but also because of scars or other signs of abuse that would be apparent to the screener in some cases.

Many of the women also pointed to loss of control or feeling vulnerable with the sample collection process (29%) and fear and anxiety about the test or the consequences of not getting tested or both (30%).

Almost 40% of the women made a comment about feeling sexually victimized by the screening, 15% saying the experience was just like the abuse they used to suffer.

Safety, trust, and difficulty of disclosing the abuse were issues brought up by one in five of the respondents. About the same proportion said they found the cervical smear tests uncomfortable and even painful.

Poor communication and lack of sensitivity by the smear taker were mentioned by 17% of the women.

Practical suggestions for making abused women more likely to undergo screening ranged from support to disclose the history of abuse to lying on the side instead of on the back during the smear collection.

Another possibility is allowing these women to collect their own cervical smear sample, the researchers noted.

"Self-sampling for HPV has been shown to be acceptable to a number of general populations of women and has comparable specificity and sensitivity to cervical cytology in trials," they pointed out.

The group cautioned about the small sample size in the exploratory study as well as the population included in it, survey respondents who were likely the women most affected by their abuse.

The study was supported by a grant from the Barts CR-UK Centre Development Fund and Cancer Research UK program grants.

The researchers reported no conflicts of interest.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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